- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $5,623.41 / $10,471.29
| Facility | | $1,949.84 | $5,623.41 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,230.27 / $1,621.81
| Professional | | $870.96 | $1,230.27 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $1,548.82
| Professional | | $1,548.82 | $1,548.82 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,445.44 / $2,089.30
| Professional | | $1,071.52 | $1,445.44 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $1,548.82 / $4,897.79
| Facility | | $54.95 | $1,548.82 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,318.26 / $10,471.29
| Professional | | $1,000.00 | $1,318.26 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $1,445.44 / $5,623.41
| Facility | | $851.14 | $1,445.44 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,318.26 / $1,778.28
| Professional | | $1,023.29 | $1,318.26 | $1,778.28 |